<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603040
Report Date: 03/14/2024
Date Signed: 03/14/2024 02:48:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/16/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221216143558
FACILITY NAME:SPRINGVILLEFACILITY NUMBER:
198603040
ADMINISTRATOR:FAN, LINDA LFACILITY TYPE:
740
ADDRESS:12755 TORCH STTELEPHONE:
(626) 337-7288
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY:43CENSUS: 30DATE:
03/14/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Linda FanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unlawful eviction.
Resident sustained injury while in care.
Resident not being provided adequate services.
Facility staff did not provide record request to authorized representative in a timely manner.
Staff not providing medication as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Elizabeth Irra and Christian Gutierrez conducted a subsequent visit to investigate the above allegations. LPAs were allowed entry by Linda Fan (Facility Administrator). LPAs discussed the purpose of today’s visit.

On 12/20/22, Licensing Program Analysts (LPA) Elizabeth Irra conducted the initial 10-day complaint visit. LPA met with Xiao Hong Dong (Staff #1/S-1) and explained the purpose of today's visit. At approximately 9:20 A.M., Linda Fan (Facility Administrator) arrived and assisted with this visit. During this visit, LPA obtained a copy of the Resident Roster and Staff Roster (with staff contact information including language preference). LPA attempted to interview Staff #1 (S-1) and Resident #1 (R-1) and was unsuccessful due to language barrier. LPA obtained relevant documentation for R-1. Additionally, LPA was unable to interview other Staff and/or Residents due to language barriers and due to active cases of COVID-19+ cases at this facility. **Refer to LIC 9099C for the continuation of this report.

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20221216143558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SPRINGVILLE
FACILITY NUMBER: 198603040
VISIT DATE: 03/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During today’s visit, LPAs interviewed Facility Administrator, Staff #1 (S-1) through Staff #3 (S-3) and interviewed Resident #2 (R-2) through Resident #4 (R-4). R-1 no longer resides at this facility and whereabouts are unknown. LPAs utilized Focus Interpreting for translation services for interviews conducted with staff and residents.

Allegation: Unlawful eviction. Interviewed staff indicated that the Facility Administrator handles eviction notices. Per Facility Administrator interview, R-1 was issued an eviction notice due to R-1 not complying with the general policies of the facility and non-payment. Per Facility Administrator, R-1’s Authorized Representative was notified of R-1’s actions. Interviews do not corroborate this allegation.

Allegation: Resident sustained injury while in care. (3) out of (4) interviewed staff indicated R-1 reported that R-1 had bumped their head on the door when R-1 was opening the door on 11/03/2022. Per staff interviews, R-1 was examined, monitored and had R-1 take an x-ray to determine if R-1 had an injury and/or fracture (no injury/fracture noted). Per staff interviews, R-1’s authorized representative was notified. A Special Incident Report (SIR) was also submitted to Community Care Licensing pertaining to this incident. Per resident interviews, residents indicated they have not witnessed any residents sustaining any injuries. Staff and resident interviews and reviewed documentation do not corroborate this allegation.

Allegation: Resident not being provided adequate services. Staff interviews revealed that residents are provided with adequate services. (3) out of (4) interviewed staff indicated R-1 was provided with showers twice per week (Tuesdays and Fridays). Per staff interviews, staff keep a bathing log for residents. (2) out of (3) interviewed residents indicated they receive showers twice per week. (1) out of (3) interviewed residents indicated staff provide them with daily showers. Staff and resident interviews and reviewed documentation do not corroborate this allegation.

Allegation: Facility staff did not provide record request to authorized representative in a timely manner. Interviewed staff indicated that the Facility Administrator handles requests pertaining to resident records. Per Facility Administrator interview, R-1’s Authorized Representative did not request R-1’s records. Interviews do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20221216143558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SPRINGVILLE
FACILITY NUMBER: 198603040
VISIT DATE: 03/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff not providing medication as prescribed. Interviewed staff indicated they provide residents with medication as prescribed. Per staff interviews, staff provided R-1 with eye drops twice per day and daily saltwater mouth wash cleaning twice per day. Interviewed residents indicated staff provide them with medication on a daily basis. Staff and resident interviews and reviewed documentation do not corroborate this allegation

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.



Exit interview conducted, a copy of the Appeal Rights and this report was provided to Linda Fan (Facility Administrator).
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3